Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
The following is a summary of the recommendations for prostatitis and chronic pelvic pain syndrome. Refer to the original guideline for more detailed recommendations and discussion.
Levels of evidence (Ia-IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Bacterial prostatitis is a disease entity diagnosed clinically and by evidence of inflammation and infection localized to the prostate. According to the duration of symptoms, bacterial prostatitis is described as either acute or chronic, when symptoms persist for at least 3 months. It is recommended that European urologists use the classification suggested by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH), in which bacterial prostatitis with confirmed or suspected infection is distinguished from chronic pelvic pain syndrome (CPPS). (The classification of prostatitis and CPPS according to NIDDK/NIH criteria is provided in the original guideline document.)
Acute bacterial prostatitis can be a serious infection. Parenteral administration of high doses of a bactericidal antibiotic is usually required, which may include a broad-spectrum penicillin, a third-generation cephalosporin, or a fluoroquinolone. All of these agents can be combined with an aminoglycoside for initial therapy. Treatment is required until there is defervescence and normalization of infection parameters (IIIB). In less severe cases, a fluoroquinolone may be given orally for 10 days (IIIB).
In chronic bacterial prostatitis, and if infection is strongly suspected in CPPS, a fluoroquinolone or trimethoprim should be given orally for 2 weeks after the initial diagnosis. The patient should then be reassessed and antibiotics only continued if pre-treatment cultures are positive and/or the patient has reported positive effects from the treatment. A total treatment period of 4-6 weeks is recommended (IIIB).
Patients with CPPS are treated empirically with numerous medical and physical modalities. Despite the existence of some scientifically valid studies, no specific recommendations have been made until now. This has been because patients with CPPS probably represent a heterogeneous group of diseases and therapeutic outcome is always uncertain.
Table 1: Antibiotics in Chronic Bacterial Prostatitis*
| Antibiotic |
Advantages |
Disadvantages |
Recommendation |
| Fluoroquinolones |
| |
- Favourable pharmacokinetics
- Excellent penetration into the prostate
- Good bioavailability
- Equivalent oral and parenteral pharmacokinetics (depending on the substance)
- Good activity against 'typical' and atypical pathogens and Pseudomonas aeruginosa
- In general, good safety profile
|
Depending on the substance:
- Drug interactions
- Phototoxicity
- Central nervous system adverse events
|
Recommend |
| Trimethoprim |
| |
- Good penetration into prostate
- Oral and parenteral forms available
- Relatively cheap
- Monitoring unnecessary
- Active against most relevant pathogens
|
- No activity against Pseudomonas, some enterococci and some Enterobacteriaceae
|
Consider |
| Tetracyclines |
| |
- Cheap
- Oral and parenteral forms available
- Good activity against Chlamydia and Mycoplasma
|
- No activity against Ps. aeruginosa
- Unreliable activity against coagulase-negative staphylococci, Escherichia coli, other Enterobacteriaceae, and enterococci
- Contraindicated in renal and liver failure
- Risk of skin sensitization
|
Reserve for special indications |
| Macrolides |
| |
- Reasonably active against Gram-positive bacteria
- Active against Chlamydia
- Good penetration into prostate
- Relatively non-toxic
|
- Minimal supporting data from clinical trials
- Unreliable activity against Gram-negative bacteria
|
Reserve for special indications |
*Adapted from Bjerklund Johansen TE, Grüneberg RN, Guibert J, Hofstetter A, Lobel B, Naber KG, Palou Redorta J, van Cangh PJ. The role of antibiotics in the treatment of chronic prostatitis: a consensus statement. Eur Urol 1998;34(6):457-466.
Definitions:
Levels of Evidence
Ia Evidence obtained from meta-analysis of randomized trials
Ib Evidence obtained from at least one randomized trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study
III Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
IV Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
